forms

keeley****Please read this entire page carefully.

Kindly complete all of the attached forms and email or send via secure fax (516.218.7964) at least 24 hours prior to your first session.  As this is an environmentally-aware practice, you may bring hard copies only if you are unable to email/fax as long as you have made me aware of this prior to your session. Please give yourself at least 30 minutes to complete the intake forms.  Completing intake paperwork prior to the initial visit affords the patient more time to talk and to make more productive use of time during the visit.  All forms are required unless otherwise noted.  I am very sorry, but patients who do not complete the intake paperwork cannot be seen. No exceptions.

REQUIRED FORMS
Scheduling & Cancellation Policy
New Patient Registration
Consent for Treatment
Privacy Policy
Insurance Correspondence – required for all patients using insurance.  Patients will need to contact their insurance carrier’s behavioral health department to correctly complete this form.  It is not recommended that patients contact the general benefits departments.
Consent for release of liability for emotional support from animals in therapy – required for all patients receiving services in Bay Ridge

OPTIONAL BUT HELPFUL FORMS
PHQ-9 Depression Screening
Mood Disorder Questionnaire 
GAD-7 Anxiety Screening
Healthy Living Questionnaire
C-SSRS Risk Rating Scale
Life Events Checklist
PCL-C Abbreviated PTSD Screening
AUDIT Alcohol Use Screening
Drug Use/Abuse Screening
PRIME Thought Patterns Screening
YFAS Eating Habits Scale

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